skills/wound-care-evidence-map/references/evidence-schema.md

# Wound-care evidence schema

Use categories relevant to the stated issue or a reasonably foreseeable downstream issue. A larger packet is not automatically a stronger packet. For pre-notice readiness, offer an inventory without inventing a denial or requiring uploads.

## Clinical episode

- Wound type, location, laterality, onset/episode boundary
- Etiology and relevant comorbidities
- Measurements and method, including date and units
- Tissue, drainage, infection findings, perfusion/vascular assessment
- Offloading, compression, pressure relief, nutrition, glycemic or tobacco factors when relevant
- Debridement and other standard/conservative care
- Response, plateau, failure, contraindication, or intolerance as actually documented
- Treatment plan, product selection rationale, application technique, follow-up, and outcome

## Administrative and product evidence

- Orders, signatures, dates, credentials, and plan-of-care links
- Claim date, code, modifiers, units, diagnosis pointers, place of service
- Product name and HCPCS; lot/serial/UDI match status and invoice-to-application match status without the actual unique numbers; acquisition and use records
- Applied amount, discarded amount, wastage modifier and documentation when applicable
- Prior authorization, ADR submission, portal receipt, remittance, denial and appeal decisions

## Evidence quality labels

- `Direct`: the record expressly documents the fact.
- `Corroborating`: another contemporaneous source supports it.
- `Inferred`: plausible but not expressly documented; do not present as fact.
- `Conflicting`: records disagree.
- `Missing`: needed source was not supplied or does not document the point.

## Relevance discipline

Distinguish a coverage or billing requirement verified for the service date, an item specifically requested by the reviewer, and helpful corroborating evidence. Do not turn photographs, labs, a fixed conservative-care duration, or a wound-reduction threshold into universal Medicare requirements. Explain whether `missing` means not supplied to this review, not located after a reported search, or absent from a specific document; none alone proves that care did not occur.

For every proposed attachment, state which current or reasonably foreseeable downstream issue it answers. The complete requested set is never narrowed to avoid a weakness. Put unrelated quality-improvement findings in the internal review, not in the appeal narrative.

## Sources

- CMS Program Integrity Manual, Chapter 3: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019033
- Arclight favorable ALJ case analysis: https://www.arclightaction.com/insights/favorable-alj-decision-wound-care-real-world-evidence
- Arclight due-process analysis: https://www.arclightaction.com/insights/due-process-denied